Insurance Help

Navigating insurance claims, appeals and getting the appropriate insurance coverage for eating disorder treatment can be a challenging process. This section includes resources including letter templates, tips regarding appeals and fighting for coverage, and local mental health insurance information.

Read more from National Eating Disorders Association (NEDA): Insurance Resources

Working with Insurance Companies to Obtain Coverage

Insurance Coverage: Tips for Navigating

Eating disorders, particularly anorexia and bulimia, are usually covered by health insurance, partly as a result of the “parity law” now in effect in California, but figuring out exactly what the coverage is can be confusing. The parity law states that certain mental health disorders, including anorexia and bulimia, will have the same maximum co-payment as those in the general medical plan. This short guide will give you some basic information to help you get the benefits to which you are entitled and also to make decisions about maintaining insurance coverage for the future.

First, you should review and be aware of the details of your policy and contract. The major insurance companies vary tremendously as to what they will cover, and every insurance company has hundreds of different policies, each with its own coverage and terms. In addition, major insurance companies often have mental health benefits, under which eating disorders coverage falls, administered by a secondary company. The best way to be clear about your benefits and your payment responsibilities is to actually read all the information sent to you about your plan, as well as any updates. While reviewing all the specifics of your policy may seem like a daunting and unpalatable task, it is well worth the time since treatment of eating disorders can be very costly.

If you still have questions about your coverage after reviewing the policy, contact your health insurance company for further explanations. Ask to speak to the insurance company representative’s supervisor for further clarification if the answers you are given do not seem to fit with the terms of your policy as you understand it. You can also ask for help from your employer’s human resources department.

Remember that you are your own best advocate when dealing with your health insurance coverage issues. You should also be aware that all insurance companies have an appeal process whenever a claim is denied, and in some cases denials of coverage are overturned on appeal.

As the parent of a son or daughter with an eating disorder, you should keep in mind the issue of ongoing, long-term health insurance coverage. It is especially important that a person with any serious or pre-existing medical condition, which includes anyone with an eating disorder, never let health insurance coverage lapse. It is likely to be difficult and extremely expensive, if not impossible, to obtain or reinstate new insurance coverage. If your child’s insurance coverage is due to end because a parent changes jobs or is laid off, or because the child will pass the age under which they are covered, be sure to check with your health insurance company and your company’s human resources department to find out how coverage can be continued. You can also contact an insurance agent to find out what options you may have for health insurance, but be sure to explain fully your child’s medical history.

Again, make certain that you consider and settle this question before your child’s coverage ends, so that there will be continuous insurance coverage.


Strategies to Counteract Insurance Denials

Information from an insurance panel at NEDA conference with:

  • Attorney Lisa S. Kantor, Esq., of Kantor & Kantor LLP, Northridge, CA
  • Stacey Brown, Director of Nursing and Utilization Review
  • David Christian, Clinical Psychologist, Avalon Hills Eating Disorders Treatment Program

Common Reasons Claims Are Denied

The panel outlined out three common reasons insurance claims are denied. The first reason involves the question of medical necessity. Parity laws require that mental health coverage be provided commensurate with medical health coverage. Second, medical stability will occur long before psychological stability. State definitions trump an insurer’s definition of medical necessity. Finally, clinicians should look for loopholes.

A second reason is exhaustion of benefits. To counteract this, clinicians, family, and patient should be very familiar with the individual policy because the company may deny benefits that are clearly included. It is also helpful to know the state’s degree of involvement with mental health parity laws, because the state may or may not participate in parity. A third reason for denial is rigidity about what the insurer thinks treatment be; for example, telephonic family treatment or partial treatment with boarding (one can legally bill for a lower level of care than what is being delivered). And, some companies attempt to selectively exclude eating disorder patients.

Read more from Eating Disorders Review:
When to challenge insurance denials and other useful information

 


How to fight for coverage of eating disorder treatment

Eating disorders can be both medically and financially devastating. The National Eating Disorders Association says as many as 10 million women and 1 million men in the U.S. battle anorexia or bulimia, and another 13 million more struggle with binge eating or an obsession with dieting. Worse, kids as young as 8 and 9 are being diagnosed with eating disorders and adolescent girls are still the No. 1 demographic for developing an eating disorder.

Read more from this Nasdaq article:
How to Fight for Coverage of eating disorder treatment


Local Mental Health Insurance Referral

County 60-Day Program
(408) 885-7855

Mental Health Advocacy Project (MHAP)
152 North Third Street, 3rd Floor
San Jose, CA 95112
(Across from Saint James Park on Third Street)
Phone (408) 280-2407
rachel.richardson@lawfoundation.org
http://www.lawfoundation.org/programMHAP.html

MHAP is working on a statewide initiative to spread the word about mental health parity laws. The basic principle is that health insurance companies must cover mental health and substance abuse disorder benefits equally to other health benefits.  With the Affordable Care Act, parity laws apply to more types of plans than ever before, so MHAP is trying to get the word out about parity protections through trainings.  In some cases, MHAP can also provide direct representation for people who run into problems with their health plans. Click here to view a flyer and FAQ about the parity project.

Healthy Families and Healthy Kids (by Santa Clara Family Health Plan)
PCP sends prior authorization referral to Santa Clara Family Health Plan: (408) 376-3532 (fax)

Once authorized, County Mental Health phones patient for an autom 3 visits. Thereafter, therapist requests more visits as needed. See additional information below under Santa Clara Family Halth Plan.
MediCal and Managed Care MediCal

Self-referral to County Mental Health Department: (800) 704-0900

Blue Cross Healthy Families Behavioral Health Programs: (800) 399-2421
Santa Clara Family Health Plan

210 E. Hacienda Avenue
Campbell, CA 95008
(800) 260-2055
www.scfhp.com

Santa Clara Family Health Plan is committed to providing quality, affordable health coverage to the uninsured and underinsured in Santa Clara County’s diverse communities. Medi-Cal coverage is free, while Healthy Families and Healthy Kids costs no more than $18 a month per family, depending on family income. As the designated community provider plan for Healthy Families in Santa Clara County, Santa Clara Family Health Plan offers these low rates for all the same benefits as the commercial plans. Santa Clara Family Health Plan is the exclusive plan to offer Healthy Kids benefits. Member benefits include comprehensive medical care such as preventive checkups, specialist care, a 24-hour nurse advice line, hospital care, prescriptions and many other services.

Santa Clara County Mental Health Department

They do not specifically have any programs for eating disorders. Patients suffering from an eating disorder enter the system through this portal: http://www.sccmhd.org/portal/site/mhd/.

Valley Health Plan Commercial
Counseling, self-referral: (408) 885-4647
12 visits, then therapist submits a treatment plan for additional visits
Psychiatry, requires Primary Care Physician referral by fax to: (408) 885-4875
5 visits, then psychiatrist submits for additional visits.


Medi-Cal Beneficiaries

Santa Clara County Emergency Psychiatric Services (EPS)

871 Enborg Lane
San Jose, CA 95128
(408) 885-6100
Available 24-hours a day. Evaluation, assessment, treatment and observation, and referral to appropriate care, including admission to a hospital when needed.

Santa Clara County Mental Health Urgent Care

871 Enborg Ct.
San Jose, CA 95128
(408) 885-7855
8am-10pm daily; walk-in or by appointment
Walk-in outpatient clinic for Santa Clara County residents experiencing a mental health crisis. Provides screening, assessment, crisis intervention, referral and short-term treatment for adolescents and adults.

Santa Clara County Suicide and Crisis Hotline

1-855-278-4204
24-hours a day
Provides phone intervention and emotional support to individuals in crisis. Highly trained volunteer counselors assist people who are feeling suicidal, experiencing distress, or just need to talk with someone who will listen.

Santa Clara County Mental Health Call Center

1-800-704-0900
For information regarding behavioral and mental health services (including eating disorders), screenings, appointments, benefits and authorizations.

Valley Connection

Valley Connection is the appointment line for Santa Clara Valley Medical Center’s primary care clinics. You can call Valley Connection to make an appointment with a SCVMC primary care physician (PCP), get a Medical Record Number, and Locate services. If you do not have a primary care physician, please contact your health plan to find out how to select your PCP.

1-888-334-1000 (English, Spanish, Vietnamese, and a number of other languages)
https://www.scvmc.org/patients/Pages/appts.aspx


Example of a Follow-up Letter from Parents

Date
Jane Doe
Case Manager
Insurance Company
City, State, Zip Code
Phone Number
Fax Number
RE: Anne B. Smith
Insurance Policy Number
DOB: 8/8/88
Dear Jane Doe:
This is a follow-up letter to summarize our phone conversation today at 3:15pm. If you have any dispute about what I say transpired, please notify me in writing (by mail or by fax) within two (2) business days of receipt of this letter. If I have not received a response by that time, then that will be tantamount to your acceptance of what I state in this letter.
In our conversation you stated that your insurance company was denying the coverage for our daughter Anne’s treatment at the West Coast Eating Disorder Treatment Center. Your stated reason for that denial was that her treatment was “not medically necessary.” I asked you to give me the name, title, and expertise regarding eating disorders of the medical director who has made the claim that this treatment is not medically necessary. You refused to give me that name in spite of my telling you that as a fully paid member I do have the right to now who in that company is making life-or-death decisions regarding my daughter. You stated also that this was “company policy.”
I, again, am asking to know what medical director made that decision and all contact information for that person, including address, direct phone number, and fax number. I am also requesting his or her qualifications to render a decision in this matter.
Your company’s delays have already cost my daughter much needed treatment time. These delays in treatment have resulted in further deterioration in her condition, ultimately extending her recovery and making it more difficult and more expensive. As time is of the essence and my daughter’s life is at risk, I can only allow a maximum of three (3) business days for a response.
 
I may be contacted at any time at the following numbers:
Sincerely,
Your Name


Example of a Letter from a Physician

Date
Jane Doe
Case manager
Insurance Company
City, State, Zip Code
Phone Number
Fax Number
Re:       Tina Smith
            Insurance I.D. #
            DOB: 01/01/88
To Whom It May Concern:
We are writing this letter to summarize our treatment recommendations for Tina Smith.
We have been following Jane in our eating disorder program since April 12, 200X. During these past two years, Tina has had six hospitalizations for medical complications of her malnutrition including profound bradycardia, hypothermia, and orthostasis.
Her hospital admissions are listed below:
Admission date – Discharge Date      Profound Bradycardia
Admission date -Discharge Date        Profound Bradycardia and Hypothermia
Admission date – Discharge Date      Bradycardia and Orthostasis
Admission date – Discharge Date      Bradycardia
Admission date – Discharge Date      Orthostasis
Admission date – Discharge Date      Bradycardia
In all, Tina has spent 11 days of the past two years in the hospital due to cardiac complications of her malnutrition.
Tina’s Malnutrition is damaging more than her heart. The following medical issues have complicated her course:
  1. Secondary amenorrhea since August 200X. This prolonged amenorrhea has the potential to cause irreversible bone damage leading to osteoporosis in her early adult life.
  2. As above, significant risk for Osteopenia. Bone density results are pending examination.
  3. Essential fatty acid deficiency, which can impact all organs, most especially her neurocognitive function.
  4. Hypophosphatemia
  5. Constipation, delayed gastric transit, and abdominal pain
  6. Leucopoenia
  7. Hypoalbuminemia
Despite receiving intensive outpatient medical, nutritional, and psychiatric treatment, Tina’s medical condition has continued to deteriorate. She has had consistent weight loss since January 200X, and is currently 83 percent of her estimated minimal ideal body weight (the weight where the nutritionist estimates she will regain her menses. Her white blood cell count and serum protein and albumin levels have been steadily decreasing as well, because of her extraordinarily poor nutritional intake.
Due to Tina’s poor nutritional progress and continued medical complications despite receiving intensive outpatient treatment for Anorexia Nervosa, it is our strong recommendation that she needs more intensive psychiatric and nutritional treatment. The type of treatment that Jane needs is offered only in a residential treatment program specializing in eating disorders. We recommend a minimum of a sixty- to ninety-day stay in a program that offers a tiered approach, with intensive residential and transitional components that focus on the care of adolescents and young adults with eating disorders. Tina requires daily psychiatric, psychological, and nutritional treatment by therapists well trained in the Treatment of her disease. She will be best served by a program that is age appropriate for her, and not a program for much older adults. In such a tiered program, Jane could get the residential treatment that she so desperately needs, and then show that she can maintain any progress in a transitional setting. We do NOT recommend treatment in a non-eating disorder specific behavioral treatment center, as Tina has a severe case of anorexia and deserves subspecialty-level care. Some examples of such programs would include (name a few programs).
Anorexia Nervosa is a deadly disease with a 10-15 percent mortality rate and 15-25 percent developing a severe lifelong course. We believe that without the intensive treatment of a residential program, Tina’s malnutrition, and the medical complication that is causes, will continue to worsen, and Tina will be at a significant risk of developing lifelong anorexia nervosa or dying of her disease. We understand that, in the past, your reviewers had denied this level of care.
This is the only appropriate and medically responsible care plan that we can recommend for Tina. We truly believe that to offer her less is medically negligent, and trust that you will share our grave concern for Tina’s need and approve such care to assist in her emotional and physical recovery. Thank you for your thorough consideration of this matter. Please feel free to contact us with any concerns regarding Tina’s care.
Sincerely,
NAME OF DOCTOR


Example of an Appeal Letter From Parents

Date
Jane Doe
Case manager
Insurance Company
City, State, Zip Code
Phone Number
Fax Number
Re: Tina Smith
       Insurance I.D. #
        Date of Birth
Dear Jane Doe:
My wife and I would like to take the opportunity to provide additional information and documentation about our daughter’s desperate need to receive inpatient treatment at NAME OF TREATMENT CENTER.
Tina’s life is in serious danger. Her treatment team, composed of an eating disorders specialist, a psychotherapist, and a registered dietitian, agree that Tina immediately requires inpatient treatment at a residential treatment program that specializes in the treatment of adolescents and young adults with eating disorders. Partial Hospitalization has been unsuccessful. Tina refuses to eat anything except an apple and maybe lettuce, and then insists on exercising to burn off the few calories she has taken in. Our lovely, once vibrant 5’2’’ daughter now weighs less than eighty pounds. She has been hospitalized four times in the last six months. Tina is desperately ill and has told us she wants to get better but is caught in the nightmare of her eating disorder. Although she is now medically stable, the treatment team believes it is likely Tina will require medical hospitalization again if she does not get help at NAME OF TREATMENT CENTER.
We were very excited to learn that NAME OF TREATMENT CENTER has an available bed. Although we recognize that it is not in your network, the only facility in your network is not appropriate for Tina because it does not specialize in treating adolescents. Our daughter is only 12 years old and we, along with her treatment team, strongly believe she needs to be at a facility that only treats women under 18. Her therapist also feels strongly that she would not be in a facility that has women in their forties and fifties who have struggled with eating disorders for many years (please see the attached copy of his evaluation). NAME OF TREATMENT CENTER was denied due to being an out-of-network facility. We would like to appeal this denial. We are prepared to seek legal counsel if INSURANCE COMPANY is unwilling to approve the treatment our daughter needs and that both her physician and therapist have recommended. The cost of sending her to NAME OF TREATMENT CENTER will be far less than the cycle of recurrent medical hospitalizations that she is currently stuck in. More importantly, it will put Tina on the path to recovery and give her back her life.
Thank you for the opportunity to appeal. We look forward to hearing from you.
Sincerely,
Your Name and Contact Info


The Insurance Appeal Pack

In addition to a letter and many forms required by the insurance company, include the following:

1. American Psychiatric Association (APA) Guidelines for Treatment of Eating Disorders
Important medical findings reviewed in the APA guidelines

  • Physical consequences of eating disorders include all serious sequelae of malnutrition, especially cardiovascular compromise.
  • Prepubertal patients may have arrested sexual maturity and growth failure
    Even those who “look and feel deceptively well,” with normal EKGs may have cardiac irregularities, variations with pulse and blood pressure, and are at risk for sudden death.
  • Prolonged Amenorrhea (less than six months) may result in irreversible Osteopenia and a high rate for fractures.
  • Abnormal CT scans of the brain are found in less than 50 percent of patients with anorexia nervosa.
  • Bulimic Behaviors may result in electrolyte, fluid, and mineral imbalance, may be presenting cardiac risk, gastric irritation and bleeds, large bowl abnormalities, dental enamel erosion, peripheral muscle weakness, cardiomyopathy, and hypo metabolism. These consequences may be present despite normal weight.
  • Bulimic patients of normal weight may also be severely malnourished and have serious nutritional deficiencies.

2. Court cases to site as precedent for medical coverage of eating disorders

  • Simmons vs. Blue Cross and Blue Shield of Greater New York, 1989
  • Starvation from Anorexia Nervosa is a physical state which should be covered by medical benefits
  • State of Minnesota vs. Blue Cross and Blue Shield of Minnesota, 2001 (for the wrongful death of Anna Westin)
  • Blue Cross/Blue Shield agreed to allow an independent panel of three experts to review denial of coverage. The majority decision is binding upon the insurance company if the policy holder is part of a state-regulated managed care system. (Unfortunately, these covered by a self-insured plan in Minnesota are not subject to state laws and therefore, for them, the panel’s decision is only advisory.)
  • After receiving a claim, Blue Cross will make an immediate decision as to payment within twenty-four hours for urgent care and within two business days for non-urgent care. Blue Cross/Blue Shield agreed to increase access to psychiatrists and other therapists and significantly increase coverage for intensive treatment of eating disorders, which until them, it had rarely covered.
  • Blue Cross had to reimburse families who paid for care out-of-pocket. The company also had agreed to consider claims by families who did not participate in the lawsuit, but who believed they were inappropriately denied coverage.
  • Manhattan vs. Travelers Insurance Company (United States District Court): Until the patient is at least 85 percent of target weight, treatment is medical and should be covered by medical benefits, even if treatment takes place in a psychiatric hospital

3. Important Studies/Research to Date

  •  Individuals who were 90% of there body mass index (BMI) or less at the time of transfer from residential treatment to a day hospital program were more than ten times likely as someone who was above 90 percent of their ideal BMI to fail day hospital treatment and require either readmission to an inpatient unit or discharge against medical advice.
  • For individuals less than 90 percent of their BMI, there is a strong economic advantage for continued inpatient treatment, because it avoids the immediate relapse and readmission for more than one third of those individuals.
  • Over the past fifteen years the treatment of eating disorders has gone from longer hospitalizations for disease management to short hospitalizations for acute stabilization (average length of stay in 1984 was 149.5 days and in 1998 was 23.7). This shift to short hospitalizations has been accompanied by a significant rise in hospital readmissions. (O percent readmissions in 1984 and 27 percent in 1988). This can significantly increase the cost and duration of treatment.
  • Patients of anorexia who are discharged and are still underweight had a 50 percent chance of readmission versus a ten percent chance for readmission for those who were discharged after full weight recovery.
    Assuming treatment consisting of inpatient weight restoration with a gradual step-down to partial hospitalization program and them outpatient treatment, the treatment is cost effective when looking at cost per year of life saved, as compared to any other medical interventions.
  • 10-15 percent of people with anorexia will die form their eating disorder. This is the highest mortality of any psychiatric illness.
  • The risk for death for people with eating disorders is increased with the longer duration of the illness.
  • 1-3 percent of people with bulimia will die.
  • The longer someone has bulimia, the worse the outcome.
  • If children and young adolescents with anorexia do not receive intensive intervention, severe and permanent stunting of growth will occur.
    People under the age of fifteen with strong eating-disordered attitudes and a low rate of weight recovery during admission, need a longer hospitalization and a period of weight management before discharge. Upon discharge, they require a step down to intensive therapy in a day program.
  • If girls with eating disorders do have stunted growth, catch-up growth is possible. However, to achieve this, they need long-standing weight gain. The sooner this is achieved the better, because the capacity for growth will eventually decline.